Rural Spinal Cord Injury Project

Rural Spinal Cord Injury Project
A collaborative project between:
Prince Henry & Prince of Wales Hospital
Royal North Shore Hospital
Royal Rehabilitation Centre Sydney
Spinal Cord Injuries Australia
JUNE 2002
Paraplegic & Quadriplegic Association of NSW
Revised 2005
Treatment of
Autonomic Dysreflexia
for adults with spinal cord injuries
A
medical
emergency
Targeting Health Professionals
© Author: Dr James Middleton, Medical Director,
Moorong Spinal Unit, Royal Rehabilitation Centre Sydney
Project funded by the Motor Accidents Authority of NSW
Autonomic Dysreflexia
Autonomic Dysreflexia, also referred to as autonomic hyperreflexia, is a potentially
life-threatening condition, which affects individuals with spinal cord injury (SCI) above
the major splanchnic outflow (typically from a lesion at or above the T6 neurological
level).
Pathophysiology
Autonomic Dysreflexia results from widespread reflex activity of the sympathetic
nervous system below the level of injury, triggered by an ascending sensory (usually
noxious) stimulus. Following stimulation, overactivity of sympathetic ganglia remains
uncontrolled due to isolation of the spinal cord below the injury from normal regulation
by vasomotor centres in the brainstem. Release of substances such as noradrenaline and
dopamine cause severe vasoconstriction with skin pallor, piloerection and a sudden rise
in blood pressure usually accompanied by a headache.
Parasympathetic activity above the level of SCI occurs when the rise in blood pressure is
sensed by baroreceptors in the aortic arch and carotid bodies, resulting in compensatory
bradycardia (via the vagus nerve). Flushing due to dilatation of blood vessels, which is
probably also responsible for headache, and profuse sweating above the level of injury
also occur (via sympathetic inhibitory outflow from vasomotor centres). However, both of
these mechanisms are insufficient to satisfactorily control paroxysmal hypertension due to
massive sympathetically-mediated vasoconstriction of the splanchnic bed.
Symptoms and signs
Common symptoms and signs of Autonomic Dysreflexia are listed in Table 1. Typically, the
patient will complain of a pounding headache with flushing and profuse sweating above
the level of spinal lesion, with or without other symptoms such as nasal congestion
(stuffiness), blurred vision, shortness of breath and/or anxiety. Skin pallor and piloerection
(goose bumps) are seen below the level of spinal lesion.
Blood pressure (BP) is significantly elevated (at least 20-40 mmHg above
normal resting systolic level). It is important to remember that BP for individuals
with high paraplegia or tetraplegia may usually be low, around 90-100/60
mmHg lying down and possibly lower whilst sitting. Therefore, patients with SCI
may become symptomatic with BP in the normal range for the population.
Autonomic Dysreflexia is a medical emergency ! If unrecognised or not treated promptly
the blood pressure may rise to dangerously high levels and precipitate intracranial
haemorrhage, encephalopathy and seizures or a cardiac arrhythmia.
Note: Women with spinal cord injury who are pregnant may experience
autonomic dysreflexia as the first sign of the commencement of labour.
1
TABLE 1 – Common symptoms and signs of Autonomic Dysreflexia (Hyperreflexia).
Sudden Hypertension
Pounding Headache
Bradycardia
Flushing / blotching of skin above spinal injury level
Profuse sweating above spinal injury level
Skin pallor and piloerection below spinal injury level
NB. People with spinal cord injuries may not
experience all symptoms or may experience
other symptoms that are peculiar to him or her.
Chills without fever
Nasal congestion
Blurred vision (dilatation of pupils)
Shortness of breath, sense of apprehension or anxiety
Common causes include:
Bladder - Distended or severely spastic bladder, urinary tract infection, bladder or kidney
stones, urological procedure or even inserting a catheter.
Bowel - Constipation, faecal impaction, rectal irritation (eg. enema or manual evacuation),
haemorrhoids.
Skin - Ingrown toenail, burns, pressure area, tight clothing.
Other - Any irritating stimulus, including fracture, epididymo-orchitis, distended stomach,
labour or severe menstrual cramping. NB. Autonomic Dysreflexia may be caused
iatrogenically by staff clamping a catheter for a procedure such as a bladder ultrasound or
kinking catheter by accident in operating theatre during a surgical procedure.
Treatment
Remember: this is a medical emergency, do not leave the patient alone.
One person should monitor blood pressure while another provides treatment.
1. Initial Steps
• Ask patient and carer if they suspect a cause.
• Elevate the patient’s head and lower the legs
(this will help lower BP while cause is identified).
• Loosen any constrictive clothing.
• Check bladder drainage equipment for kinks or other causes of obstruction
to flow, such as clogging of inlet to leg bag or overfull leg bag.
• Monitor BP every 2-5 minutes.
• Avoid pressing over the bladder.
2.Further Treatment
If symptoms persist or blood pressure remains elevated following the above efforts
or a cause cannot be readily identified, pharmacological treatment with a short acting anti-hypertensive medication should be commenced concurrently with
the search for and treatment of the noxious stimulus. The blood pressure threshold at
which medication should be given may vary a little depending on the type of intervention
being undertaken (ranging between 150-170mmHg); for instance, at lower end of the BP
range for m a n u a l e v a c u a t i o n c o m p a re d w i t h h i g h e r e n d o f ra n g e f o r u re t h ra l
catheterisation due to potentially greater and more prolonged nociceptive stimulus expected
with former (refer to Treatment Algorithm).
2
3.1 For a person with an indwelling urethral or
suprapubic catheter
i. If a blocked catheter is suspected, empty the leg bag and estimate volume.
To help determine if bladder is empty or not, consider patient’s fluid intake and
output earlier that day and normal pattern of drainage.
ii. If catheter seems blocked, irrigate the bladder GENTLY with no more than 30mls of
sterile normal saline.
iii. If urine does not drain after irrigation, re-catheterise using a generous amount of
lubricant containing a local anaesthetic e.g. Lignocaine 2% gel. In men with an
indwelling urethral catheter, ensure adequate anaesthetic jelly is injected into urethra
and prevented from leaking out by constricting penis for 2 – 3 minutes, to relax external
urethral sphincter prior to recatheterisation.
3.2 For a person wearing a uridome or doing
intermittent self-catheterisation
If bladder is distended and patient is unable to void in their usual manner, lubricate the
urethra with a generous amount of lignocaine 2% gel, wait 2 – 3 minutes and then pass
a catheter to empty the bladder. Initially drain 500mls, then further 250mls every 15
minutes until bladder is empty. Leave catheter in situ until reason for retention is identified
and remedied.
NB. Be alert for sudden hypotension due to rapid drainage of bladder and/or sudden
resolution of Autonomic Dysreflexia. If blood pressure declines after bladder is empty, the
person still requires close observation as the bladder can go into severe contractions
causing hypertension to recur (see Pharmacological Treatment).
3.3 If hypertension recurs in the presence
of an indwelling catheter then:
i. Instill Lignocaine for injection (10mls of 1% solution) via a catheter, flush with a
further 10mls of saline and clamp for 5 minutes. This can be repeated 2nd hourly for 6
doses if necessary.
ii.
4.
Administer an oral anticholinergic medication (e.g. Oxybutynin).
For Faecal Evacuation
If you are sure the bladder is empty and symptoms persist, gently insert a generous amount
of Lignocaine gel into the rectum. Wait five minutes before gently inserting a finger to
remove faecal matter.
N.B. Blood pressure may rise rapidly during rectal examination with person positioned in
side-lying. Monitor BP manually before commencing and during digital stimulation; if
blood pressure increases significantly, cease digital stimulation and only recommence
under cover of 10mg oral Nifedipine tablet (refer to Treatment Algorithm).
3
5.
Pharmacological Treatment
Note: BEFORE ADMINISTERING PHARMACOLOGICAL TREATMENT, ALWAYS CHECK FOR
INTERCURRENT AND/OR RECENT USE OF MEDICATION FOR ERECTILE DYSFUNCTION
i. Oral Agents
Glyceryl Trinitrate (GTN):
DO NOT USE GTN SPRAY, TABLETS OR PATCH IF A MEDICATION FOR ERECTILE DYSFUNCTION
SUCH AS SILDENAFIL (VIAGRA), VARDENAFIL (LEVITRA) OR OTHER PDE 5 INHIBITOR (NITRIC
OXIDE ENHANCER) HAS BEEN TAKEN IN LAST 24 HOURS, OR TADALAFIL (CIALIS) HAS BEEN
TAKEN WITHIN THE LAST FOUR DAYS.(Refer to Manufacturers Product Information for further
pharmaceutical information.)
• Administer one spray of GTN (400mcg Nitrolingual Pump Spray) OR if spray is
unavailable, place 1/2 GTN tablet (300mcg Anginine) under tongue, or apply one
5mg GTN Transdermal Patch to chest or upper arm. (Patch should be removed as
soon as hypertension resolves.)
• Monitor BP, if little or no effect in 5-10 minutes administer a second spray or other half
tablet of Anginine under tongue. Be cautious, particularly with elderly patients, when
administering GTN spray or tablet as sudden hypotension may result, particularly if cause is
quickly remedied. Dosage may be titrated by spitting out residual spray or tablet with
hypotensive effect being short lasting.
• Up to 3 doses can be given in 30 minutes (if BP remains elevated or rises rapidly
intravenous medication may be indicated - see below).
DO NOT USE SILDENAFIL (VIAGRA), VARDENAFIL (LEVITRA) OR OTHER DRUG IN THE PDE
5 INHIBITOR (NITRIC OXIDE ENHANCER) CLASS WITHIN 24 HOURS OF TAKING GTN
SPRAY OR TABLETS.
“Nitrates” include glyceryl trinitrate (injection, tabs, sprays and patches), isosorbide salts, sodium
nitroprusside, amyl nitrate or organic nitrates in any form .
Nifedipine (Adalat) tablets:
• If GTN spray, tablets or patch are unavailable or contraindicated (due to recent use of
medication for erectile dysfunction within the last 24 hours see guidlelines above), swallow
one Nifedipine 10mg tablet (not slow release tablet) with water. It will take longer
(approximately 15-20 minutes) to begin to act.
ii. Parenteral Agents
If hypertension is not relieved by GTN or Nifedipine, then administration of parenteral antihypertensives will be required in an acute hospital setting. Adequate analgesia (e.g.
Morpheine) should be administered where there is a known cause of nociception. Where
control of the noxious stimulus is difficult, regional epidural anaesthesia may be appropriate.
NB. An acute episode of Autonomic Dysreflexia can lead to an increased susceptibility to
further episodes over the next 24-72 hours. These may be precipitated by activities
which would not normally do so, e.g. muscle stretches, bowel care, etc. The patient must
be alerted to this possibility and monitored appropriately.
IF A CAUSE CAN NOT BE FOUND AND / OR THE PROBLEM REMAINS UNRESOLVED,
PLEASE CONTACT YOUR NEAREST ACUTE SPINAL INJURIES UNIT AND/OR SPINAL UNIT
PHYSICIAN ON CALL FOR FURTHER ADVICE AND MANAGEMENT.
Royal North Shore Hospital Main Switch
Prince of Wales Hospital Main Switch
(02) 9926 7111
(02) 9382 2222
4
TABLE 2 – Summary of recommended treatment/interventions with accompanying rationale
derived from Clinical Practice Guidelines for “Acute Management of Autonomic Dysreflexia”,
Consortium for Spinal Cord Medicine, Paralysed Veterans of America, 1997.
5
Action/Intervention
Rationale
Check blood pressure (BP) with
manual sphygmomanometer.
Assess if BP is elevated (NB. Automatic BP
measuring devices eg. Dynamap are too slow to
detect rapid rises in BP).
If blood pressure is elevated
- sit patient as upright as possible
- remove all tight clothing including abdominal
binders
Encourages pooling of blood in lower extremities
and abdomen to reduce BP and buffer rises in BP.
Obtain assistance from other staff member
Two people are required to monitor and treat
patient.
Monitor BP and pulse rate every 2-5 minutes until
episode has completely resolved.
Blood pressure will continue to rise, often rapidly,
until successfully treated. It is essential to continue
monitoring BP closely during all interventions and
until the episode has resolved with BP returning to
normal resting level.
Perform thorough survey of the patient to
determine cause of Autonomic Dysreflexia.
Episode of Autonomic Dysreflexia will not resolve
until cause is identified and rectified.
Beginning with urinary system:
The urinary tract, particularly bladder distension, is
the commonest cause of Autonomic Dysreflexia.
If catheter is insitu
- Check entire catheter system for kinks, folds,
obstructions
- If problem such as kink identified, rectify
immediately
Obstruction of urine outflow may result in bladder
overdistension.
- If catheter appears to be blocked, gently irrigate
bladder with small amount of normal saline at body
temperature
Irrigation may remove blockage.
Large volume of fluid instilled in bladder may
further exacerbate Autonomic Dysreflexia.
- If catheter is not draining, remove and replace
the catheter
OR
Existing catheter may be blocked with sediment or
blood. It is essential to decompress bladder.
New catheter should run freely.
If catheter is not insitu insert urinary catheter
Bladder distension is the most common urinary
cause.
NB. Prior to inserting catheter instill 2%
Lignocaine gel (if readily available) into the
urethra and wait 2-5mins if possible.
Insertion of catheter may exacerbate Autonomic
Dysreflexia. Lignocaine gel may decrease sensory
input and relax sphincter for catheterisation.
NB. Initially drain 500mls then further 250mls
every 15 minutes until bladder is empty.
**Be alert for sudden hypotension due to rapid
draining of bladder and/or sudden resolution of
Autonomic Dysreflexia.
If the catheter is draining and BP remains elevated
continue to next step.
Clinical evidence suggests urinary system is not the
cause of Autonomic Dysreflexia.
Allowing unobstructed flow of urine may resolve
episode.
If BP continues to be elevated, suspect faecal
impaction as the cause:
Faecal impaction is the second most common cause
of Autonomic Dysreflexia.
- Instill a generous amount of local Anaesthetic
(eg Lignocaine) gel,
Local Anaesthetic will be required, even if patient has
no or markedly reduced sensation, since PR check
and/or manual removal of faeces may exacerbate
Autonomic Dysreflexia.
- Wait approximately 5 minutes before performing
gentle PR examination.
Wait to allow action of Lignocaine.
- If BP ≥ 150mmHg, consider pharmacological
management to reduce systolic BP without causing
hypotension prior to PR and/or faecal disimpaction.
Medication will help to control precipitous rises in BP
Clinical judgement is essential when making decisions
about pharmacological management, taking into
account the actual BP level and how rapidly BP is
changing.
- If necessary perform manual evacuation using
generously lubricated gloved finger - gently remove
any stool which is present.
If cause is faecal impaction, Autonomic Dysreflexia
will not resolve until removal of stool.
- If symptoms of Autonomic Dysreflexia worsen, STOP
manual removal immediately and instill additional
Lignocaine. Wait a further 5 minutes or longer before
trying again, depending on whether administering a
medication (e.g. Nifedipine).
Digital stimulation may exacerbate Autonomic
Dysreflexia.
If PR check reveals no stool in the rectum, continue
to next step.
Commence systematic survey of patient for other
causes of Autonomic Dysreflexia, eg.
- Pressure area
- Post operative irritation or pain
- Ingrown toe nail
- Burn
- Fracture
If no cause can be found and symptoms persist
obtain assistance from Spinal Unit Consultant.
Autonomic Dysreflexia will not resolve without finding
and remedying underlying cause.
Medical assistance is required for additional
treatment and control of symptoms – Patient may
require intravenous pharmacological intervention to
prevent complications such as CVA.
Episode is considered to be resolved when:
- Cause of Autonomic Dysreflexia has been identified
- Blood pressure restored to normal level for individual
- Pulse returned to normal rate
- Patient is comfortable with no signs of Autonomic
Dysreflexia
Following resolution of episode:
- Monitor patient (BP and Pulse) for 4 hours post
episode
- Document episode, cause and treatment in notes
Some ‘Hyperactivity’ of the sympathetic nervous system
may be experienced. Patient should be monitored for
any exacerbation or reappearance of symptoms, so
they can be quickly and appropriately treated.
Educate patient, carers, significant others
Additional education may be required to help
recognition of symptoms, treatment and strategies to
avoid further episodes as much as possible.
It is important to also alert the patient and
carers to the possibility of increased
susceptibility to further episodes over following
few days.
6
Reading
Bashford G. Medical management of spinal cord impairment. 1. Autonomic Dysreflexia. Current Ther 65-71, 1997.
Braddom RL, Rocco JF. Autonomic Dysreflexia: A survey of current treatment. Am J Phys Med Rehabil 70: 234-241, 1991.
Colochais SC III. Autonomic Hyperreflexia with SCI. J Am Parapl Soc 15: 171-186, 1992.
Consortium for Spinal Cord Medicine. Clinical Practice Guidelines: Acute Management of Autonomic Dysreflexia. Adults
with Spinal Cord Injury presenting to Healthcare Facilities, Paralysed Veterans of America, 1997.
Erickson RP. Autonomic Hyperreflexia: Pathophysiology and Medical Management.
Arch Phys Med Rehabil 61: 432-440, 1980.
contributors
Dr Stella Engel
(Director, NSW State Spinal Cord Injury Service,
Rehabilitation & Spinal Medicine, Prince of Wales Hospital)
Dr Sue Rutkowski
(Director, Spinal Cord Injury Outpatient Services & Research,
Royal North Shore Hospital)
acknowledgements
Dr Douglas Brown (Director, Victorian Spinal Cord Services)
Dr Jane Watt (LMO, Armidale)
Jane Temblett (Spinal Adviser, Paraquad)
Daphne Davis (Spinal Adviser, Paraquad)
Rita Cusmiani (RN, Moorong Spinal Unit, Royal Rehabilitation Centre Sydney)
Georgia Cairns (CNS, Moorong Spinal Unit, Royal Rehabilitation Centre Sydney)
rural spinal cord injury project
Should you require any further copies of this document go to www.paraquad.nsw.asn.au
and follow the links from information to publications or go to:
www.ciap.health.nsw.gov.au and follow the specialties link or contact,
NSW State Spinal Cord Injury Service (SSCIS)
Tel: 9382 5645 Fax: 9382 5620
This document was published as a fact sheet for the Rural Spinal Cord Injury Project (RSCIP), a pilot healthcare program for people
with spinal cord injuries (SCI) conducted within New South Wales. It is not a stand alone resource but part of a series of eight fact
sheets produced by specialists to fulfil the educational components of the project.
All recommendations are for spinal patients as a group. Individual therapeutic decisions must be made by combining the
recommendations with clinical judgement, including a detailed knowledge of the individual patient’s unique risks and medical
history, as well as the resources available. This document is published as a guide only and does not take the place of advice from
your regular health professional and /or medical practitioner.
Printed by The Dominion Group (02) 9689 1888
Dr Bon San Bonne Lee (Rehabilitation Physician, Prince of Wales Hospital)